Finally, using the same arguments as palliative care supporters, the CCNE report states that refusal of treatment sometimes expresses a call for help and should be understood as such by the medical team. Following the discussions around the Humbert case, a new law was passed in [ 51 ]. The law also promoted the development of palliative care. Although the law of aimed to strengthen the respect for patient autonomy, it was also evidence of ambivalence towards that autonomy. This paradox, or the struggle to respect patient autonomy, also showed in the value attributed to advance directives to refuse treatment when patient are no longer able to express their wishes.
Until , advance directives only had advisory value in French law. The law of stated that the physician may take these documents into account but is not obliged to respect them. From the very beginning, the law was discussed as a provisional legal framework. Several cases which were discussed in the media showed its limitations in addressing the following: A parliamentary report of confirmed the shortcomings of the law and its application in medical practice [ 52 ]. This resulted in a new report being published by a parliamentary committee in [ 53 ].
Firstly, the report suggested granting greater value to advance directives, i. The report recommended that palliative care should be provided from the very moment the patient is diagnosed with a serious illness, and continuous deep sedation should be offered at the request of patients deciding to discontinue life-sustaining treatment, e. This term, so long associated with palliative care, expresses the duty of society towards dying patients and their loved ones, a duty which implies a confrontation with death, a fight against the feeling of abandonment and loneliness, and finally, equal access to palliative care.
The report of also refers to solidarity but includes respect for autonomy as a new element in the accompagnement of dying patients. However, the text indicates that accompagnement had become a central theme in the reflection about end-of-life care. According to the report, accompagnement is considered necessary to coping with the fear of abandonment and the anxiety of dying felt by many patients. It is also seen as an important element in encouraging people to openly discuss end-of-life issues.
At a political level, social inequalities in access to end-of-life care and support for proxies must also be dealt with. Finally, accompagnement is also associated with an attitude of respect for patient wishes. The importance of respect for patient autonomy is no longer questioned. Two years later, in , the CCNE report on the public debate about the end of life made a similar use of the notion of accompagnement [ 54 ] and discussed the same association between autonomy and solidarity.
Once again, the respect for patient autonomy is associated with the concern to guarantee social solidarity in the last stage of life. As a result of further debates and another parliamentary report in [ 56 ], a new law on end of life issues came into force early in A closer analysis of this law shows, however, that although respect for autonomy is now considered an important value, its implementation is not straightforward.
The same paragraph L. If a physician refuses to implement an advance directive, this decision is re-examined in a so-called collegial procedure i. As Thouvenin points out, the decision of whether to apply an advance directive remains a medical decision. According to French law, only physicians are able to validate the authenticity or appropriateness of a previously expressed patient wish [ 58 ]. Although French law has increasingly strengthened the right of competent patients to make their own decisions, this is not the case for patients who are no longer competent to express their will, even if they have a previously written advanced directive.
However, the situation has not remained the same in the course of the debate; a way to combine autonomy and solidarity has been found that makes it possible to argue in favour of respect for patient autonomy. Today, in France, those who advocate respect for patient autonomy are sometimes doing so for the sake of individual self-determination.
Such respect is also justified on the basis of an autonomy that is conceived as a shared collective value. In this perspective, respect for patient wishes is seen as a leading principle in end-of-life care, not because of a rights-based individualistic conception, but because of the social duty to address the needs of dying patients. It is thus on the basis of social solidarity that the respect for patient autonomy has become legitimate in end-of-life care.
As we will show in the following section, the support of terminally ill patients expresses this new combination between solidarity and autonomy. From the s on, the French debate regarding end-of-life care was intense and heated. However, it did not refer to the notion of autonomy. Patients had no right to decide about their end-of-life care. In retrospect, this social and legal pattern may be considered paternalistic.
Hence, autonomy could not be employed on its own as a principle to justify respect for patient wishes. It, however, remained an isolated view. From , in the aftermath of the Humbert case, accompagnement was increasingly presented as an important part of medical practice, particularly where active treatment was foregone.
Accompagnement was no longer exclusively linked to the provision of care for dying patients but also applied to all patients who refused treatment, even if they were not in the last stage of their life. Henceforth, accompagnement represented respect for patient wishes, beliefs, and values. Physicians were now expected to provide continuous support for patients even if they refuse further treatment. The term accompagnement began to embrace more than just palliative care, and was extended to care in general, whether it was medical, spiritual, or social.
Increasingly, the patient became the centre of attention as a person with her or his own beliefs and values [ 59 ]. This vision of accompagnement strengthened the position of the patient at the end of life only up to a certain extent. It expressed an ethical concern about professional attitudes towards dying patients rather than actually focusing on patient self-determination. From , the debate focused on the question of whether patient wishes could be challenged at all.
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In this context, the support of patients was perceived as part of a broader social commitment not to abandon the dying person, while respecting their wishes, rather than submitting them to paternalistic medicine. Accompagnement was understood as a way of expressing solidarity, both at an individual and a social level.
It is widely used to describe good professional practice, not only in medical contexts, but also in the broader context of social community care and education. Facilitated by the ordinariness of the term in French language and its broad acceptance in French society, it allows its users to describe a viable combination of autonomy and solidarity. It is not a theoretical justification of this combination, but it is an effective rhetorical tool for conveying the combination in the public debate, both at an ethical and legal level. On the one hand, accompagnement allows acceptance of patient autonomy within some limits, as we will see below.
In legal terms, since February , this means that patients who are able to express their will are entitled to receive every necessary intervention to alleviate their pain. Patients may also refuse medical treatment, including nutrition and hydration. Finally, the law sets up a procedure for continuous deep sedation when the suffering of the patient is considered unbearable and the patient is in her last stage of life.
If communitarianism is understood as a perspective that places the needs of society over those of the patient, France does not opt for a communitarian approach to end-of-life care when combining solidarity with autonomy. A different pattern is set by the recent shift of the French debate about end-of-life care: Here, solidarity is not opposed to autonomy: This conception develops a social as opposed to an atomistic understanding of human life and personal identity [ 12 ].
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Thinking of oneself as existing within the limits of society thus appears as the condition for the recognition of individual freedom. This combination also relates to a conception of solidarity understood as the expression of a shared social duty towards dying and vulnerable patients. This conception also entails that granting patient autonomy a central position does not entail the moral legitimacy of every request to die.
The increased focus on patient autonomy in French society has its limits when speaking of autonomy as self-determination. For example, the most recent law of does not allow euthanasia, even in exceptional cases.
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These differences cannot be ignored despite the attempt to harmonise autonomy and solidarity, as described in this article. As we have stressed, there is still strong disagreement as to how much autonomy should be granted to a patient at the end of life both when patients are able to express their will and when they are not and have left advanced directives [ 55 ]. Our article shows how the association of the ideas of solidarity and autonomy led to the social acceptance of the latter in the French context. Whereas solidarity is a determining value in French society, at least within the French health care system, respect for patient autonomy has long been considered a foreign concept, deriving from the liberal Anglo-American tradition.
At first, respect for patient autonomy was associated with the right to a self-determined death, a request that seemed incompatible with French values, which are based on a model of social cohesion and emphasises the protection of vulnerable members of society such as dying persons. Patient autonomy was only gradually recognised as an important value in the French end-of-life debate, yet to this day, its practical implementation is not evident and its scope remains restricted.
The respect for patient wishes was associated with some kind of social duty towards the dying person, and now appears as being consistent with the general will of society as a whole. It is precisely this association between autonomy and solidarity that allows the leading moral principle of solidarity to define the limits of individual self-determination.
In the French context, this association leads to a definition of autonomy that is promoted as a common social value, on the one hand, and limited by social values such the protection of the dying person, on the other hand. In this definition, solidarity and autonomy become two compatible values, although this compatibility is limited. We see this as an important contribution to the bioethical debate, which has been inclined to emphasise the incompatibility of Anglo-American and Continental European values.
This article extends and develops the discussion we began during a workshop held on February 16—17, , at Linacre College in Oxford.
We are grateful to the participants who contributed to discussion of the paper and to Susan Barrington for reviewing the text. We would particularly like to thank Ruud ter Meulen for his detailed comments on earlier drafts of this article. National Center for Biotechnology Information , U. Theoretical Medicine and Bioethics. Published online Dec 3. Marie Gaille 1 and Ruth Horn 2. Author information Copyright and License information Disclaimer.
Abstract This article traces the way autonomy has become a recognised value in health care in France. Introduction Continental European and Anglo-Saxon approaches to health care are often associated with two seemingly opposed conceptions of care: Scope and limits of associating autonomy with solidarity From the s on, the French debate regarding end-of-life care was intense and heated.
Conclusion Our article shows how the association of the ideas of solidarity and autonomy led to the social acceptance of the latter in the French context. Acknowledgements This article extends and develops the discussion we began during a workshop held on February 16—17, , at Linacre College in Oxford. Compliance with ethical standards Conflict of interest None.
Footnotes 1 We would like to point out that the French end-of-life debate mainly focuses on cases that take place in a hospital setting. Contributor Information Marie Gaille, Email: Bien mourir—Sociologie des soins palliatifs. Faire vivre et laisser mourir—Le gouvernement contemporain de la naissance et de la mort. La valeur de la vie. Les Belles Lettres; Le droit de mourir—Choisir sa fin de vie en France et en Allemagne. Presses Universitaires de Rennes; Patient preferences at the end-of-life and physician attitudes towards advance directives in England and France.
Medicine, Health Care and Philosophy. Gautier C, Laugier S. Moral breakdown and the ethical demand. Presses Universitaires de Laval; The many faces of autonomy.
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In Solidarity in health and social care in Europe , eds. European values in bioethics: Why, what, and how to be used. DCL tests cover five skill sets:. There are two versions of the DCL: Delivered by the Ministry of Education, the DCL is a professional national diploma intended specifically for the adults. This is a general French language proficiency test for all non-French speakers who, for professional or personal reasons, wish to obtain quick, simple, reliable certification of their knowledge in French.
The test places candidates on a six-level scale corresponding to the six levels of the European Framework for Languages. It also places candidates on the European Framework for Languages six-level scale. Students wishing to enrol in first-year courses at a French university can sit for the TEF tests. Under the new provisions introduced by the French Interior Ministry, as of 1 January , all persons needing to justify their level of French proficiency as part of an application for French citizenship must now qualify for the B1 level in spoken French.
Every person that must prove its level of French to acquire the French nationality has to bring the proof which she has the level required by knowledge of the national language, that is the level B1 but only in the oral: The applicants have to produce: Le Certificat Voltaire A level certification in spelling.
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